What are the treatment options for hypertriglyceridemia?

From the Guidelines

Treatment for hypertriglyceridemia should start with lifestyle modifications, including dietary changes and regular physical activity, and may require medication if triglycerides remain elevated, with the goal of reducing morbidity, mortality, and improving quality of life. The most effective lifestyle interventions for reducing triglyceride levels include weight loss of 5-10% of body weight, reducing intake of refined carbohydrates, sugars, and alcohol, and increasing consumption of omega-3 fatty acids found in fatty fish 1. Regular physical activity of at least 150 minutes per week of moderate-intensity exercise is also recommended 1. If triglycerides remain above 500 mg/dL despite lifestyle changes, medications such as fibrates, prescription omega-3 fatty acids, or statins may be necessary 1. Fibrates like fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily) are commonly prescribed, while prescription omega-3 fatty acids such as icosapent ethyl (2 grams twice daily) or omega-3 acid ethyl esters (2-4 grams daily) are also effective 1. Statins may be added if LDL cholesterol is also elevated, and niacin (1-2 grams daily) can lower triglycerides but has more side effects 1. The goal of treatment is to bring triglycerides below 150 mg/dL to reduce the risk of pancreatitis and cardiovascular disease, ultimately improving morbidity, mortality, and quality of life 1. Key considerations in treatment include:

• Assessing cardiovascular risk factors and liver dysfunction 1
• Using fibrates as first-line treatment in patients with hypertriglyceridemia who are at risk of pancreatitis 1
• Considering combination therapy with fibrates, niacin, and n-3 fatty acids for patients with moderate to severe hypertriglyceridemia 1
• Monitoring lipid levels regularly to assess treatment effectiveness 1

From the FDA Drug Label

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcoholic intake may be important factors in hypertriglyceridemia and should be addressed prior to any drug therapy. Physical exercise can be an important ancillary measure Diseases contributory to hyperlipidemia, such as hypothyroidism or diabetes mellitus should be looked for and adequately treated. Estrogen therapy, thiazide diuretics and beta-blockers, are sometimes associated with massive rises in plasma triglycerides, especially in subjects with familial hypertriglyceridemia In such cases, discontinuation of the specific etiologic agent may obviate the need for specific drug therapy of hypertriglyceridemia. Fenofibrate tablets are indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.

The treatment options for hypertriglyceridemia include:

• Dietary therapy: specific for the type of lipoprotein abnormality
• Lifestyle modifications: addressing excess body weight and excess alcoholic intake, and incorporating physical exercise
• Treatment of underlying diseases: such as hypothyroidism or diabetes mellitus
• Discontinuation of etiologic agents: such as estrogen therapy, thiazide diuretics, and beta-blockers
• Pharmacologic therapy: with fenofibrate tablets as an adjunct to diet, at an initial dose of 54 mg per day to 160 mg per day, with a maximum dose of 160 mg once daily 2 2

From the Research

Treatment Options for Hypertriglyceridemia

The treatment options for hypertriglyceridemia include:

• Lifestyle modifications, such as cessation of alcohol consumption, reduced intake of rapidly metabolized carbohydrates, weight loss, and blood sugar control, which are the most effective ways to lower triglyceride (TG) levels 3
• Therapeutic lifestyle changes (TLC), including a low saturated fat, carbohydrate-controlled diet, combined with alcohol reduction, smoking cessation, and regular aerobic exercise 4
• High doses of omega-3 fatty acids from fish and fish oil supplements, which can lower TG levels significantly 4
• Drug therapy, including:
  • Fibrates, which can lower TG concentrations, but their efficacy in combination with statins has not been clearly shown in endpoint studies 3
  • Omega-3-acid ethyl esters, which can effectively decrease TG levels by up to 45% 5
  • Statins, which can exhibit a significant hypotriglyceridemic activity in high doses 6
  • Niacin, which can be considered in patients with low HDL levels and hypertriglyceridemia 4
  • Orlistat, which can interfere with chylomicron production and is useful for hypertriglyceridemic patients 6
• Combination therapy, which may be necessary in recalcitrant cases 4, 6
• Gene therapy, which is under development for patients with known genetic abnormalities of triglyceride metabolism 6

Special Considerations

• Patients with very high TG levels (> or = 500 mg/dL) should be promptly managed and treated to reach lipid treatment goals, as determined by the National Cholesterol Education Program (NCEP) 5
• Patients with severe hypertriglyceridemia and abdominal pain or pancreatitis should be hospitalized and treated with hypolipidemic drugs and, if needed, with insulin/dextrose infusion or therapeutic apheresis 6
• Patients with the very rare purely genetic types of hypertriglyceridemia (familial chylomicronemia syndrome) should be treated in specialized outpatient clinics 3